Review
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►► Additional material is
published online only. To view
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​​
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For numbered affiliations see
end of article.
Correspondence to
Dr Kathryn J Schneider, Sport
Injury Prevention Research
Centre, Faculty of Kinesiology
University of Calgary, 2500
University Drive N.W. Calgary,
Alberta T2N 1N4, Canada;
k​ jschnei@​ucalgary.c​ a
Accepted 28 February 2017
Published Online First
9 March 2017
To cite: Schneider KJ,
Leddy JJ, Guskiewicz KM,
et al. Br J Sports Med
2017;51:930–934.
1 of 7
Rest and treatment/rehabilitation following
sport-related concussion: a systematic review
Kathryn J Schneider,1 John J Leddy,2 Kevin M Guskiewicz,3 Tad Seifert,4
Michael McCrea,5 Noah D Silverberg,6 Nina Feddermann-Demont,7,8 Grant L Iverson,9
Alix Hayden,10 Michael Makdissi11,12
ABSTRACT
Aim or objective  The objective of this systematic
review was to evaluate the evidence regarding rest and
active treatment/rehabilitation following sport-related
concussion (SRC).
Design  Systematic review.
Data sources  MEDLINE (OVID), CINAHL (EbscoHost),
PsycInfo (OVID), Cochrane Central Register of Controlled
Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID)
and Proquest DissertationsandTheses Global (Proquest)
were searched systematically.
Eligibility criteria for selecting studies Studies
were included if they met the following criteria: (1)
original research; (2) reported SRC as the diagnosis;
and (3) evaluated the effect of rest or active treatment/
rehabilitation. Review articles were excluded.
Results  Twenty-eight studies met the inclusion criteria
(9 regarding the effects of rest and 19 evaluating active
treatment). The methodological quality of the literature
was limited; only five randomised controlled trials
(RCTs) met the eligibility criteria. Those RCTs included
rest, cervical and vestibular rehabilitation, subsymptom
threshold aerobic exercise and multifaceted collaborative
care.
Summary/conclusions  A brief period (24–48 hours)
of cognitive and physical rest is appropriate for most
patients. Following this, patients should be encouraged
to gradually increase activity. The exact amount and
duration of rest are not yet well defined and require
further investigation. The data support interventions
including cervical and vestibular rehabilitation and
multifaceted collaborative care. Closely monitored
subsymptom threshold, submaximal exercise may be of
benefit.
Systematic review registration PROSPERO
2016:CRD42016039570
Introduction
Sport-related concussion (SRC) is among the most
common sport and recreation injuries.1 2 Most
athletes recover gradually over the initial days
following injury, but up to 15% have been reported
to have time loss of at least 30 days.3 After a concus-
sion, a period of cognitive and physical rest until the
acute symptoms resolve followed by a progressive
return to activity according to a protocol of graded
exertion is recommended.4 This advice is based on
expert opinion and was developed at sequential
consensus meetings on concussion in sport.4–6
The symptoms and problems following concus-
sion can vary considerably, and athletes can also
experience associated injury to the cervical spine or
Schneider KJ, et al. Br J Sports Med 2017;51:930–934. doi:10.1136/bjsports-2016-097475
peripheral vestibular system. Therefore, a variety of
treatments may be required that address ongoing
symptoms and impairments following injury.7 8 The
purpose of this systematic review was to evaluate
the evidence related to two questions: (1) What is
the evidence that rest is beneficial following concus-
sion, and is there an optimal duration of rest? (2)
What is the evidence that active treatment and
rehabilitation is effective for athletes who have
experienced SRC?
Methods
The initial search terms used in this systematic
review, the inclusion criteria, exclusion criteria and
database selection were generated and reviewed
by the author group. The draft MEDLINE search
strategy was then sent to an expert librarian (KAH)
to ensure its completeness and accuracy. This was
done according to the PRESS Guideline Statement
using the CADTH Peer Review Checklist.9 The
librarian revised and expanded the MEDLINE
search, and then translated it for the other data-
bases (see online supplementary tables S1 and S2).
An a priori data extraction table was generated and
approved by all authors.
The following electronic databases were
searched: MEDLINE (OVID), CINAHL (Ebsco-
Host), PsycInfo (OVID), Cochrane Central Register
of Controlled Trials (OVID), SPORTDiscus (Ebsco-
Host), EMBASE (OVID) and Proquest Dissertations
and Theses Global (Proquest). The search was run by
the expert librarian and exported for review for the
author group (up to and including articles published
until 17 October 2016) (see online supplementary
tables S1 and S2). Duplicates were removed. Refer-
ences of included papers and systematic reviews
were searched for additional references and authors
were asked to share any additional references that
met the inclusion criteria. The total yield of arti-
cles was divided into half and the title and abstract
of each article was independently reviewed for
inclusion by two authors for each question (four
authors in total). To be considered for inclusion in
this review, articles had to (1) be original research
(including RCTs, quasi-experimental designs, case
series, case cross-overs and case studies, cohort
and case control), (2) have the focus of the study
be SRC as a source of injury and (3) evaluate the
effect of rest or treatment. Review articles and arti-
cles published in abstract form only were excluded.
In the case of disagreement or uncertainty between
the two reviewers, a third reviewer was engaged
to resolve the discrepancy and where required,

full-text manuscripts were retrieved to determine eligibility for
inclusion.
Full texts were retrieved for all included articles, which were
then subcategorised as per the main topics of rest and treat-
ment. Two authors independently extracted data for each of the
articles and independently evaluated the risk of bias using the
Downs and Black (DB) checklist for methodological quality.10
In the case of a discrepancy, the authors discussed the differ-
ence in rating and came to a final rating. In the event that the
authors were unable to come to a consensus, a third rater was
engaged. We used this checklist because we anticipated a variety
of study designs, and this checklist is appropriate for assessing
randomised and non-randomised studies. A higher rating on the
DB checklist indicates a lower risk of bias. Studies scoring below
a 5 on the DB checklist were removed from the review due to a
high risk of bias. Data were extracted using standardised tables
and included the following: study design, participants (sample
size, age, sex, sampling methods), treatment (frequency, inten-
sity, type, timing/duration), outcome measures, key findings
(point estimates with 95% confidence intervals) and level of
evidence (per Oxford Centre for Evidence Based Medicine).11
Extracted data were synthesised qualitatively. We present a
qualitative synthesis of the available data regarding the effec-
tiveness and duration of rest following SRC, and a qualitative
synthesis of the available data regarding the effectiveness of
treatment and rehabilitation for athletes with SRC. Meta-anal-
yses were not performed because the intervention and outcome
data were heterogeneous.
Results
A total of 8224 citations were identified via the electronic data-
base search and 2518 duplicates were removed. Four other
records were identified for a total of 5710 citations. Of the four
additional record identified by authors, three were not captured
in the initial search as they did not mention sports or related
keywords in the abstract or indexing and one did not include
terms relevant to treatment or rest. A third reviewer was engaged
to assess inclusion following screening of title and abstract for
35 records in which there was disagreement. Forty-one records
were reviewed in full text and 29 records met the inclusion
criteria (see figure 1 for PRISMA flow diagram). One study was
subsequently removed from the review due to its high risk of
bias (DB score=2) resulting in a total of 28 studies (see online
supplementary table S3).
A total of 3218 participants (ages 5–53) were included in this
systematic review. The studies (five RCTs, nine cohort studies,
two quasi-experimental studies, 12 case series) had varying
scores on the DB criteria with the RCTs scoring highest—DB
range: 18–25, cohort studies—DB: 7–23, quasi-experimental—
DB: 15–21 and case series—DB: 6–16.
Rest
Nine studies examined rest following concussion (see online
supplementary table S3). Six studies included both children and
adults and three studies included only children. There was one
eligible RCT that evaluated the effects of strict rest following
SRC in adolescents and found that both groups had a 20%
decrease in total energy expenditure following injury.12 The
individuals who were randomised to recommendation of strict
rest reported higher total symptom over 10 days and had slower
symptom resolution.12 Two non-randomised treatment studies
recruiting from the same specialty clinic reported benefit from
Schneider KJ, et al. Br J Sports Med 2017;51:930–934. doi:10.1136/bjsports-2016-097475
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a period of 1 week of prescribed cognitive and physical rest.13
14
Greater activity level was associated with shorter symptom
duration in one observational study15 and longer symptom dura-
tion in another.16 Two cohort studies found that self-report or
parent-report of prescription of rest did not predict a longer
recovery.17 18 Two retrospective studies did not find a signifi-
cant association between recommended cognitive rest and time
to symptom resolution.19 20 In summary, there is conflicting
evidence on the efficacy of rest following concussion on recovery
of premorbid function and symptom resolution.
Treatment
Nineteen studies evaluated the effects of treatment following
SRC (see online supplementary table S3). The majority (16/19
studies) reported positive effects with treatment but many were
at high risk of bias (DB scores ranging from 6 to 25 with 11/19
scores below 16). Common methodological limitations included
lack of a control group, lack of randomisation and lack of
control for confounders. One RCT demonstrated positive effects
with multimodal physiotherapy21 and two RCTs evaluated the
effects of subsymptom threshold aerobic exercise training—one
identifying a positive effect22 and the other found no difference
with training.23 The other RCT evaluated collaborative care,
including advocacy and coordination with schools regarding
accommodations and motivational interviewing, cogni-
tive–behavioural therapy (CBT) and psychopharmacological
consultation.24 Other treatments that reported positive effects
included a physiotherapy programme,25 26 cognitive therapies,27
medical treatments using amitriptyline,28 amantadine,29 periph-
eral nerve blocks (including greater occipital nerve blocks)30 and
exercise interventions including submaximal aerobic training
in children31 32 and adults.33–36 Individuals who performed the
greatest activity level were found to have worse performance in
visual memory, but not other cognitive domains, in one study.37
No difference was seen in symptoms or clinical recovery when
participants were exposed to a symptom-free waiting period
prior to returning to play.38 39
In summary, there is moderate evidence that targeted cervical
and vestibular physiotherapy is more effective than typical rest
followed by graded exertion to facilitate medical clearance to
return to sport. There is limited evidence that collaborative
care (including CBT, psychopharmacological consultation and
care management) reduces symptoms and improves health-re-
lated quality of life in youth. There is conflicting evidence
that subsymptom threshold aerobic exercise decreases time
to recovery; however, the majority of literature suggests a
positive effect. There is no evidence to minimal evidence that
medical treatments are of benefit to facilitate recovery following
concussion.
Discussion
Most consensus and agreement statements for managing SRC4 40
41
recommend that athletes rest until they become symptom-free.
Accordingly, prescribed rest is one of the most widely used inter-
ventions in this population.42–45 At least three rationales for rest
have been articulated. First, rest probably mitigates postcon-
cussion symptoms, easing discomfort during the acute recovery
period. Second, rest might promote recovery by minimising
energy demands during haemodynamic and neurometabolic
restoration following concussion.46–48 Third, athletes are at an
increased risk for sustaining a recurrent concussion within the
first 7–10 days after the initial concussion.38 A repeat concussion
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 Review
Figure 1  PRISMA flow diagram as follows: Records after duplicates removed 5710; records screened 5710 and Records excluded 5669.
during this period of recovery might have a magnified effect.49–51
Note that this last rationale for rest is for restricting sport partici-
pation and other preinjury activities with an elevated concussion
risk rather than for restricting all usual activities (ie, complete
rest).
There is currently insufficient evidence that prescribing
complete rest facilitates recovery following SRC. Observational
studies report mixed findings regarding whether physical or
mental activity during the days to weeks after SRC are associated
with faster or slower recovery times.15 16 19 20 37 Student athletes
reported fewer symptoms and performed better on cognitive
testing following a week of prescribed rest.13 14 However, the
high risk of bias in these uncontrolled and non-randomised
studies leaves doubt as to whether the positive outcomes were
attributable to prescribed rest versus pre-existing differences,
natural recovery, expectations/placebo effects or other thera-
peutic aspects of the clinical encounter.
There is limited higher quality evidence from RCTs that
recruited athletes and non-athletes from an emergency depart-
ment. In an RCT involving adults with concussions due to
mostly (90%) non-sport causes, prescribing 6 days of complete
rest (versus encouraging patients to mobilise and limit their bed
rest starting on the day after injury) was associated with less
dizziness in the first 4 days but bed rest was not associated with a
meaningful difference in clinical outcomes at 2 weeks, 3 months
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or 6 months following injury.52 Adolescents with concussion
who were prescribed complete rest for 5 days reported more
symptoms over the 10-day observational period compared
with adolescents who received usual care, typically including
advice to rest for 1–2 days.12 The two groups performed simi-
larly on balance and cognition outcomes. Of note, adherence to
prescribed complete rest was modest in both these trials, which
may have contributed to the small differences between the inter-
vention groups. This also highlights the practical challenges of
implementing prescribed rest. In children, self-reported physical
activity within 7 days of concussion was associated with reduced
risk of persistent postconcussive symptoms at 28 days following
injury.53
In summary, the best available evidence from clinical studies
does not support the efficacy of prescribing complete rest for
more than a few days after SRC. Both observational and exper-
imental laboratory studies have demonstrated that bouts of
intense physical or mental activity can exacerbate symptoms
in concussed athletes.54–58 These exacerbations appear to be
transient54 58 59 and further research is needed to understand
the underlying pathophysiology and potential impact on long-
term outcomes. In the interim, athletes can be encouraged to
gradually resume their non-sport activities as tolerated, avoiding
heavy exertion and activities that have an elevated concussion
risk until they are medically cleared. Prescribing rest for more
Schneider KJ, et al. Br J Sports Med 2017;51:930–934. doi:10.1136/bjsports-2016-097475

than a few days should be weighed against the possible harms
of prolonged activity restriction, especially in elite sports.60–62
However, shortening the rest period should not necessarily mean
rapid return to sport. Timing of return to sport remains a chal-
lenge especially given the evidence for a period of vulnerability
to reinjury in some athletes following concussion and should be
guided by a multimodal clinical assessment.
Treatment: rehabilitation
Historically, rest followed by a protocol of graded exertion has
been the treatment of choice following SRC.4 6 However, a more
active approach to rehabilitation may be of benefit.7 25 31–34 63
64
Our systematic review identified five studies that evaluated
rehabilitative techniques following concussion, one of which
was an RCT evaluating multimodal physiotherapy treatment
(DB score 25), one RCT evaluating collaborative care (DB score
19) and three case series evaluating cognitive rehab (DB score
12) and multifaceted physical therapy and exercise (DB score 9
and 11). For individuals with persisting symptoms of dizziness,
neck pain and headaches, a combination of cervical and vestib-
ular rehabilitation has positive treatment effects in both youth
and young adults compared with standard care (rest followed by
graded exertion).21 Treatment was individualised and was based
on persisting impairments in cervical and vestibular function.21
Multifaceted physiotherapy treatment regimes that include
adaptation, balance, musculoskeletal, aerobic, anaerobic and
sport-specific exercises might be useful.25 26 However, poor
methods (including poor description of the endpoint of return
to full activity) limit the conclusions that can be drawn.
There is a large body of evidence demonstrating positive treat-
ment effects with vestibular rehabilitation for individuals with
vestibular disorders.65–67 Vestibular rehabilitation is safe and
effective for peripheral vestibular disorders including unilateral
peripheral vestibular hypofunction and benign paroxysmal posi-
tional vertigo.65–68 Additionally, studies evaluating the effects of
vestibular rehabilitation have demonstrated positive symptom-
atic and functional improvements in patients who have suffered
mild traumatic brain injuries (mTBI) of all types, including blast
injuries.69–71 Thus, vestibular rehabilitation may be appropriate
for individuals with persistent vestibular findings following SRC.
A combination of specific exercises and manual therapy that
focus on function is effective for improving pain and function
in individuals with cervical spine pain and cervicogenic head-
aches.72 Thus, inclusion of exercise and manual therapy in the
case of ongoing cervical spine pain and cervicogenic headaches
following concussion may be of benefit.
For individuals with mTBI, there is some evidence to support
the use of an educational pamphlet73 74 and CBT.75–78 A recent
RCT that employed a multifaceted collaborative treatment
protocol including motivational interviewing, school accom-
modations, CBT and psychopharmacological therapy (where
indicated) identified a positive treatment effect on postcon-
cussive symptoms and health-related quality of life.24 Further
research to determine the efficacy of rehabilitative strategies
evaluating other areas that may be affected by SRC such as
cognition, mood, psychological disorders, sleep disturbance and
others, in isolation as well as in combination, is required.
Treatment: exercise
In articles included in our systematic review, concussed male and
female athletes with persistent symptoms lasting between 1 and
12 months were typically introduced to subsymptom submaximal
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(light) aerobic exercise multiple times per week. Overall, oursys-
tematic review supports the notion that controlled exercise
performed at an intensity and duration that does not exacer-
bate symptoms is likely safe and beneficial for adult athletes
with persistent symptoms following concussion. Athletes in the
submaximal exercise groups typically reported fewer symptoms,
recovered to baseline on cognitive and balance scores faster, and
in one study34 demonstrated more efficient activation patterns
on functional Magnetic Resonance Imaging (fMRI) relative
to matched controls. One RCT in adolescents demonstrated a
positive treatment effect with subsymptom exacerbation aerobic
training on symptom ratings; however, poorer adherence to
exercise was reported in the aerobic training group compared
with the stretching group.79 The other RCT demonstrated no
difference between groups in time to recovery.80
Studies involving children and adolescent athletes experiencing
symptoms for at least 4 weeks following concussion showed
similar improvements after completion of a progressive rehabil-
itation programme.31 32 All young athletes returned to a normal
lifestyle and full sport participation. While more robust RCTs
are needed, these findings suggest that closely monitored active
rehabilitation programmes involving controlled subsymptom
threshold, submaximal exercise for adults and adolescents with
persistent symptoms after concussion may be of benefit.
Treatment: medical
Three studies on medical treatment of SRC were identified. All
studies were retrospective case series with moderate risk of bias
scores. Two of the studies described the treatment of post-trau-
matic headaches (PTH) with either interventional or traditional
pharmacological measures. There is limited evidence to support
various medical management strategies for SRC, including the
treatment of PTH. There are no available data from RCTs eval-
uating the therapeutic efficacy of medical interventions specific to
PTH (in athletes or otherwise), although a small number of case
reports and cohort studies have recently been published. The data
from studies suggesting that certain pharmacotherapeutics may be
effective treatment strategies in the context of PTH have not shown
that medical intervention hastens recovery following SRC.28 81 82
Treatment: other (symptom-free waiting period)
The results of the two studies evaluating the effects of a symp-
tom-free waiting period suggest that outcomes, such as risk of
reinjury, may be more closely associated with an initial period
of vulnerability to reinjury than with apparent symptom resolu-
tion. Therefore, these findings highlight the importance of injury
recognition and prudent return to play decision making by clini-
cians during the first 10 days after SRC.
Two RCTs in our review included interventions that involved
more than one type of treatment and demonstrated positive
effects.24 63 Because concussion is an injury with heterogeneous
symptom and functional presentations of patients, multifaceted
rehabilitation protocols may be of benefit to facilitate recovery.
Further research in this area is needed.
Limitations
Most of the studies included in this review were of low meth-
odological quality and biased by systematic errors. Our review
may be subject to a publication bias. This review may be subject
to a language bias as we only included articles published in the
English language. We only included studies that evaluated rest or
treatment for SRC. There may be other treatments of potential
4 of 7
 Review
benefit that have been evaluated in this population but were not
identified by our inclusion criteria.
Suggestions for future research
The current literature contains few high-quality studies and
many of the current studies included in this review have a high
risk of bias. Future studies should evaluate the optimal timing,
mode, duration, intensity and frequency of treatment during
the postacute time period following concussion, ideally through
RCTs, where feasible. To facilitate research and improve the
clinical care of PTH, use of the International Classification of
Headache Disorders (ICHD) 3 beta standardised criteria is pref-
erable due to its precise classification methods. Further research
evaluating rest and active treatments should be performed using
high-quality designs that account for potential confounding
factors and effect modifiers.
Conclusion
After a brief period (24–48 hours) of complete rest, patients can
be encouraged to become gradually and progressively more active
while staying below their cognitive and physical symptom exacerba-
tion thresholds. Athletes should avoid heavy exertion and activities
with an elevated risk of head injury while they are recovering. The
exact amount and duration of rest is not yet well defined.
A variety of treatments may be required for ongoing symp-
toms and impairments following concussion. Interventions
including cervical and vestibular rehabilitation (for individuals
with persisting dizziness, cervical spine pain and headaches) and
closely monitored active rehabilitation programmes involving
controlled subsymptom threshold, submaximal exercise could be
considered. Specific treatment recommendations can be directed
based on clinical examination findings and symptoms.
Author affiliations
1
Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
2
Department of Orthopaedics, SUNY Buffalo, Buffalo, New York, USA
What is already known?
►► An initial period of cognitive and physical rest following
concussion is recommended—followed by a progression of
gradually increasing activity.
►► The literature evaluating the effects of treatment following
concussion is limited.
What are the new findings?
►► The exact amount and duration of rest is not yet well
defined.
►► After a brief period (24–48 hours) of complete rest, patients
can be encouraged to become gradually and progressively
more active while staying below their cognitive and physical
symptom exacerbation thresholds.
►► Research supports interventions including cervical and
vestibular rehabilitation (for individuals with persisting
dizziness, cervical spine painand headaches). Closely
monitored active rehabilitation programmes involving
subsymptom threshold and submaximal exercise are safe
and may facilitate recovery. Multifaceted collaborative
treatments (including cognitive–behavioural therapy, school
accommodations and pharmacotherapy) may also be of
benefit.
5 of 7
Br J Sports Med: first published as 10.1136/bjsports-2016-097475 on 24 March 2017. Downloaded from http://bjsm.bmj.com/ on 26 February 2019 by guest. Protected by copyright.
3
Sports Medicine Research laboratory, University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina, USA
4
Norton Healthcare, Louisville, Kentucky, USA
5
Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin,
USA
6
Department of Medicine, University of British Columbia, Vancouver, British
Columbia, Canada
7
Department of Neurology, University Hospital Zurich, Zurich, Switzerland
8
Schulthess Clinic, Zurich, Switzerland
9
Physical Medicine and Rehabilitation, Harvard Medical School; and Red Sox
Foundation and Massachusetts General Hospital Home Base Program, Boston,
Massachusetts, USA
10
Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
11
Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health -
Austin Campus, Heidelberg, Victoria, Australia
12
Olympic Park Sports Medicine Centre, Melbourne, Australia
Competing interests  KS has received speaking honoraria for presentations
at scientific meetings. She is a physiotherapy consultant at Evidence Sport and
Spinal Therapy in Calgary, Alberta, Canada and for athletic teams. KG is the
Founding Director of the Matthew Gfeller Sport-Related TBI Research Center at
the University of North Carolina, USA. He is a member of the National Collegiate
Athletic Association's Concussion Committee and the US Soccer Federation
(unpaid consultant for both). KG at times receives honoraria and reimbursement
of expenses to speak at professional meetings. TS is a member of the Speakers
Bureau, Avanir Pharmaceuticals. MMC receives research funding from the National
Collegiate Athletic Association (NCAA). NS reports a research salary grant from
the Vancouver Coastal Health Research Institute, grants and consultant fees from
WorkSafeBC, consultant fees from the National Hockey League, receiving salary
from the Vancouver Coastal Health Authority and Home Base, a Red Sox Foundation
and Massachusetts General Hospital programme, outside the submitted work.
GI has been reimbursed by the government, professional scientific bodies and
commercial organisations for discussing or presenting research relating to MTBI
and sport-related concussion at meetings, scientific conferences and symposiums.
He has a clinical practice in forensic neuropsychology involving individuals who
have sustained mild TBIs (including athletes). He receives support from the Harvard
Integrated Program to Protect and Improve the Health of National Football League
Players Association Members. He acknowledges unrestricted philanthropic support
from the Mooney-Reed Charitable Foundation and ImPACT Applications, Inc. MM is
a consultant Sport and Exercise Medicine physician at Olympic Park Sports Medicine
Centre and team physician for the Hawthorn football club (Australian Football
League, AFL). He receives research funding from the Australian Football League
(AFL) and non-financial support from CogState Pty Ltd. He has attended meetings
organised by the IOC, National Football League (USA), National Rugby League
(Australia) and FIFA (Switzerland); however has not received any payment, research
funding, or other monies from these groups other than for travel costs. He is an
honorary member of concussion working/advisory groups for AFL, Australian Rugby
Union and World Rugby.
Provenance and peer review  Not commissioned; externally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
References
1 Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among
youth ice hockey players. Jama 2010;303:2265–72.
2 Black AM, Sergio LE, Macpherson AK. The epidemiology of concussions: number
and nature of concussions and time to recovery among female and male Canadian
varsity Athletes 2008 to 2011. Clin J Sport Med 2017;27:52–6.
3 Kerr ZY, Zuckerman SL, Wasserman EB, et al. Concussion symptoms and return to
play time in youth, high school, and college American football Athletes. JAMA Pediatr
2016;170:647.
4 McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion
in sport: the 4th international conference on concussion in sport held in Zurich,
November 2012. Br J Sports Med 2013;47:250–8.
5 McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of
the 2nd international conference on concussion in sport, Prague 2004. Br J Sports
Med 2005;39:i78–i86.
6 McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in
sport 3rd international conference on concussion in sport held in Zurich, November
2008. Clin J Sport Med 2009;19:185–200.
7 Schneider KJ. Sport-Related concussion: optimizing treatment through Evidence-
Informed practice. J Orthop Sports Phys Ther 2016;46:613–6.
8 Marshall S, Bayley M, McCullagh S, et al. Clinical practice guidelines for
mild traumatic brain injury and persistent symptoms. Can Fam Physician
2012;58:257e128–6740.
Schneider KJ, et al. Br J Sports Med 2017;51:930–934. doi:10.1136/bjsports-2016-097475

9 McGowan J, Sampson M, Salzwedel DM, et al. PRESS peer review of electronic
search strategies: 2015 guideline Statement. J Clin Epidemiol 2016;75:40–6.
10 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the
methodological quality both of randomised and non-randomised studies of health
care interventions. J Epidemiol Community Health 1998;52:377–84.
11 Oxford Level of Evidence Working Group, 2011. Oxford Centre for Evidence-Based
Medicine 2011 Levels of Evidence
12 Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute
concussion: a randomized controlled trial. Pediatrics 2015;135:213–23.
13 Moser RS, Schatz P, Glenn M, et al. Examining prescribed rest as treatment for
adolescents who are slow to recover from concussion. Brain Inj 2015;29:58–63.
14 Moser RS, Schatz P. A case for mental and physical rest in youth sports concussion:
it’s never too late. Front Neurol 2012;3:171.
15 Howell DR, Mannix RC, Quinn B, et al. Physical activity level and symptom duration
are not associated after concussion. Am J Sports Med 2016;44:1040–6.
16 Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration
of post-concussion symptoms. Pediatrics 2014;133:e299–e304.
17 Corwin DJ, Zonfrillo MR, Master CL, et al. Characteristics of prolonged concussion
recovery in a pediatric subspecialty referral population. J Pediatr 2014;165:1207–15.
18 Eisenberg MA, Andrea J, Meehan W, et al. Time interval between concussions and
symptom duration. Pediatrics 2013;132:8–17.
19 Gibson S, Nigrovic LE, O’Brien M, et al. The effect of recommending cognitive rest on
recovery from sport-related concussion. Brain Inj 2013;27:839–42.
20 Moor HM, Eisenhauer RC, Killian KD, et al. The relationship between adherence
behaviors and recovery time in adolescents after a sports-related concussion: an
observational study. Int J Sports Phys Ther 2015;10:225–33.
21 Schneider K, Meeuwisse W, Nettel-Aguirre A, et al. Cervico-vestibular physiotherapy
in the treatment of individuals with persistent symptoms following sport-related
concussion: a randomized controlled trial. Brain Injury 2014;28(5-6):796.
22 Kurowski BG, Hugentobler J, Quatman-Yates C, et al. Aerobic exercise for
adolescents with prolonged symptoms after mild traumatic brain injury: an
exploratory randomized clinical trial. J Head Trauma Rehabil 2016.
23 Maerlender A, Rieman W, Lichtenstein J, et al. Programmed physical exertion
in recovery from Sports-Related concussion: a randomized pilot study. Dev
Neuropsychol 2015;40:273–8.
24 McCarty CA, Zatzick D, Stein E, et al; Seattle Sports Concussion Research
Collaborative. Collaborative care for adolescents with persistent postconcussive
symptoms: a randomized trial. Pediatrics 2016;138:e20160459.
25 Hugentobler JA, Vegh M, Janiszewski B, et al. Physical therapy intervention strategies
for patients with prolonged mild traumatic brain injury symptoms: a case series. Int J
Sports Phys Ther 2015;10:676–89.
26 Grabowski P, Wilson J, Walker A, et al. Multimodal impairment-based physical
therapy for the treatment of patients with post-concussion syndrome: a retrospective
analysis on safety and feasibility. Phys Ther Sport 2017;23:22–30.
27 Sohlberg MM, Ledbetter AK. Management of persistent cognitive symptoms after
Sport-Related concussion. Am J Speech Lang Pathol 2016;25:138–49.
28 Bramley H, Heverley S, Lewis MM, et al. Demographics and treatment of
adolescent posttraumatic headache in a regional concussion clinic. Pediatr Neurol
2015;52:493–8.
29 Reddy CC, Collins M, Lovell M, et al. Efficacy of amantadine treatment on symptoms
and neurocognitive performance among adolescents following sports-related
concussion. J Head Trauma Rehabil 2013;28:260–5.
30 Dubrovsky AS, Friedman D, Kocilowicz H. Pediatric post-traumatic headaches and
peripheral nerve blocks of the scalp: a case series and patient satisfaction survey.
Headache 2014;54:878–87.
31 Gagnon I, Galli C, Friedman D, et al. Active rehabilitation for children who are slow
to recover following sport-related concussion. Brain Inj 2009;23:956–64.
32 Gagnon I, Grilli L, Friedman D, et al. A pilot study of active rehabilitation for
adolescents who are slow to recover from sport-related concussion. Scand J Med Sci
Sports 2016;26:299–306.
33 Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom
threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med
2010;20:21–7.
34 Leddy JJ, Cox JL, Baker JG, et al. Exercise treatment for postconcussion syndrome:
a pilot study of changes in functional magnetic resonance imaging activation,
physiology, and symptoms. J Head Trauma Rehabil 2013;28:241–9.
35 Clausen M, Pendergast DR, Willer B, et al. Cerebral blood flow during treadmill
exercise is a marker of physiological postconcussion syndrome in female Athletes. J
Head Trauma Rehabil 2016;31:215–24.
36 Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in
pediatric sports-related concussion: safety, clinical use, and patient outcomes. J
Neurosurg Pediatr 2016;25:693–702.
37 Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity
levels, symptoms, and neurocognitive performance. J Athl Train 2008;43:265–74.
38 McCrea M, Guskiewicz K, Randolph C, et al. Effects of a symptom-free waiting
period on clinical outcome and risk of reinjury after sport-related concussion.
Neurosurgery 2009;65:876–83.
Schneider KJ, et al. Br J Sports Med 2017;51:930–934. doi:10.1136/bjsports-2016-097475
Review
Br J Sports Med: first published as 10.1136/bjsports-2016-097475 on 24 March 2017. Downloaded from http://bjsm.bmj.com/ on 26 February 2019 by guest. Protected by copyright.
39 Pfaller AY, Nelson LD, Apps JN, et al. Frequency and outcomes of a Symptom-Free
waiting period after Sport-Related concussion. Am J Sports Med 2016;44:2941–6.
40 Broglio SP, Cantu RC, Gioia GA, et al; National Athletic Trainer’s Association. National
athletic trainers’ Association position statement: management of sport concussion. J
Athl Train 2014;49:245–65.
41 DeMatteo C, Stazyk K, Singh SK, et al; Ontario Neurotrauma Foundation.
Development of a conservative protocol to return children and youth to activity
following concussive injury. Clin Pediatr 2015;54:152–63.
42 Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion knowledge base, clinical
practises and needs for continuing medical education: a survey of family physicians
and cross-border comparison. Br J Sports Med 2013;47:54–9.
43 Arbogast KB, McGinley AD, Master CL, et al. Cognitive rest and school-based
recommendations following pediatric concussion: the need for primary care support
tools. Clin Pediatr 2013;52:397–402.
44 Stoller J, Carson JD, Garel A, et al. Do family physicians, emergency department
physicians, and pediatricians give consistent sport-related concussion management
advice? Can Fam Physician 2014;60:548–52.
45 Zemek R, Eady K, Moreau K, et al. Canadian pediatric emergency physician
knowledge of concussion diagnosis and initial management. Cjem
2015;17:115–22.
46 Giza CC, Hovda DA, Da H. The neurometabolic cascade of concussion. J Athl Train
2001;36:228–35.
47 Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive
brain injury - an update. Phys Med Rehabil Clin N Am 2016;27:373–93.
48 Wells EM, Goodkin HP, Griesbach GS. Challenges in determining the role of rest
and exercise in the management of mild traumatic brain injury. J Child Neurol
2016;31:86–92.
49 Vagnozzi R, Tavazzi B, Signoretti S, et al. Temporal window of metabolic brain
vulnerability to concussions: mitochondrial-related impairment--part I. Neurosurgery
2007;61:379–89.
50 Longhi L, Saatman KE, Fujimoto S, et al. Temporal window of vulnerability to
repetitive experimental concussive brain injury. Neurosurgery 2005;56:364–74.
51 Laurer HL, Bareyre FM, Lee VM, et al. Mild head injury increasing the brain’s
vulnerability to a second concussive impact. J Neurosurg 2001;95:859–70.
52 de Kruijk JR, Leffers P, Meerhoff S, et al. Effectiveness of bed rest after mild traumatic
brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg
Psychiatry 2002;73:167–72.
53 Grool AM, Aglipay M, Momoli F, et al; Pediatric Emergency Research Canada (PERC)
Concussion Team. Association between early participation in physical activity
following acute concussion and persistent postconcussive symptoms in children and
adolescents. Jama 2016;316:2504–14.
54 Balasundaram AP, Sullivan JS, Schneiders AG, et al. Symptom response following
acute bouts of exercise in concussed and non-concussed individuals - a systematic
narrative review. Phys Ther Sport 2013;14:253–8.
55 Leddy JJ, Baker JG, Kozlowski K, et al. Reliability of a graded exercise test for
assessing recovery from concussion. Clin J Sport Med 2011;21:89–94.
56 Dematteo C, Volterman KA, Breithaupt PG, et al. Exertion testing in youth with mild
traumatic brain injury/Concussion. Med Sci Sports Exerc 2015;47:2283–90.
57 McGrath N, Dinn WM, Collins MW, et al. Post-exertion neurocognitive test failure
among student-athletes following concussion. Brain Inj 2013;27:103–13.
58 Silverberg ND, Iverson GL, McCrea M, et al. Activity-Related symptom exacerbations
after pediatric concussion. JAMA Pediatr 2016;170:946–53.
59 Brooks BL, Low TA, Daya H, et al. Test or rest? computerized cognitive testing in the
emergency department after pediatric mild traumatic brain injury does not delay
symptom recovery. J Neurotrauma 2016;33:2091–6.
60 DiFazio M, Silverberg ND, Kirkwood MW, et al. Prolonged activity restriction after
concussion: are we worsening outcomes? Clin Pediatr 2016;55:443–51.
61 Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”:
recommendations for activity resumption following concussion in athletes, civilians,
and military service members. J Head Trauma Rehabil 2013;28:250–9.
62 Craton N, Leslie O. Is rest the best intervention for concussion? lessons learned from
the whiplash model. Curr Sports Med Rep 2014;13:201–4.
63 Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular physiotherapy
in the treatment of individuals with persistent symptoms following sport related
concussion: a randomised controlled trial. British Journal of Sports Medicine
2014;48:1294–8.
64 Peters M, Price J. The peters/price (see to play) vision concussion protocol: diagnosis
and treatment? Optometry & Visual Performance 2015;3:126–38.
65 Hilton M, Pinder D. The epley manoeuvre for benign paroxysmal positional Vertigo--a
systematic review. Clin Otolaryngol Allied Sci 2002;27:440–5.
66 Hilton M, Pinder D. The epley (canalith repositioning) manoeuvre for benign
paroxysmal positional Vertigo. Cochrane Database Syst Rev 2004;2:CD003162.
67 Hillier S, Hollohan V. Vestibular rehabilitation for unilateral peripheral vestibular
dysfunction. Cochrane Database Syst Rev 2007;17:CD005397.
68 Shepard NT, Telian SA, Smith-Wheelock M, et al. Vestibular and balance
rehabilitation therapy. Ann Otol Rhinol Laryngol 1993;102:198–205.
6 of 7
 Review
69 Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and
balance disorders after concussion. J Neurol Phys Ther 2010;34:87–93.
70 Gottshall K. Vestibular rehabilitation after mild traumatic brain injury with vestibular
pathology. NeuroRehabilitation 2011;29:167–71.
71 Gottshall K, Gray N, Drake AI. A unique collaboration of female medical providers
within the united states armed forces: rehabilitation of a marine with post-
concussive vestibulopathy. Work 2005;24:381–6.
72 Gross A, Kay TM, Goldsmith C, et al; Cervical Overview Group. Exercises for
mechanical neck disorders. Cochrane Database Syst Rev 2015;28:CD004250.
73 Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome
after mild traumatic brain injury in children. Pediatrics 2001;108:1297–303.
74 Ponsford J, et al. Impact of early intervention on outcome following mild head injury
in adults. Journal of Neurology, Neurosurgery & Psychiatry 2002;73:330–2.
75 Ponsford J, Lee NK, Wong D, et al. Efficacy of motivational interviewing and cognitive
behavioral therapy for anxiety and depression symptoms following traumatic brain
injury. Psychol Med 2016;46:1079–90.
76 Tiersky LA, Anselmi V, Johnston MV, et al. A trial of neuropsychologic rehabilitation in
mild-spectrum traumatic brain injury. Arch Phys Med Rehabil 2005;86:1565–74.
7 of 7 Schneider KJ, et al. Br J Sports Med 2017;51:930–934. doi:10.1136/bjsports-2016-097475
Br J Sports Med: first published as 10.1136/bjsports-2016-097475 on 24 March 2017. Downloaded from http://bjsm.bmj.com/ on 26 February 2019 by guest. Protected by copyright.
77 Snell DL, Surgenor LJ, Hay-Smith EJ, et al. A systematic review of psychological
treatments for mild traumatic brain injury: an update on the evidence. J Clin Exp
Neuropsychol 2009;31:20–38.
78 Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions
after mild traumatic brain injury: a systematic review. results of the international
collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil
2014;95:S257–S264.
79 Kurowski BG, Hugentobler J, Quatman-Yates C, et al. Aerobic exercise for
adolescents with prolonged symptoms after mild traumatic brain injury: an
exploratory randomized clinical trial. J Head Trauma Rehabil 2016.
80 Maerlender A, Rieman W, Lichtenstein J, et al. Programmed physical exertion
in recovery from Sports-Related concussion: a randomized pilot study. Dev
Neuropsychol 2015;40:273–8.
81 Gladstone J. From psychoneurosis to ICHD-2: an overview of the state of the art in
post-traumatic headache. Headache 2009;49:1097–111.
82 Kuczynski A, Crawford S, Bodell L, et al. Characteristics of post-traumatic headaches
in children following mild traumatic brain injury and their response to treatment: a
prospective cohort. Dev Med Child Neurol 2013;55:636–41.